Biochemical Variability of Nasal Cartilages: Implications in Functional Rhinoplasty.

INTRODUCTION: Nasal valve compromise is a common issue for patients presenting to an otolaryngologist. Anatomically, the dorsal septal cartilage (DSA) articulates with the upper lateral nasal cartilage (ULC). When the ULC weakens, it is prone to collapse and may result in nasal obstruction. Our objectives were to analyze histological differences between quadrangular and DSA nasal cartilages and compare histological composition of these tissues among patients with diagnosis of nasal valve compromise (NVC) versus those without NVC (no NVC). METHODS: Prospective cross-sectional study of nasal cartilages from seventy-three (73) live donors. Quadrangular cartilage (QC), and DSA from patients undergoing septorhinoplasty were collected. Safranin O histochemical staining was used to observe glycosaminoglycans (GAGs) content and cell count. Masson's Trichrome staining was used to assess collagen content in these nasal cartilages. RESULTS: Mean GAG content was lower in DSA compared with QUAD cartilage (68.18% vs. 87.22%, p < 0.0001), and was lowest in DSA of patients with NVC (59.07%). Mean collagen content was higher in DSA compared with QUAD cartilage, (65.43% vs. 46.65%, p = 0.0002), and was highest in DSA of patients with NVC (74.86%). CONCLUSION: The DSA showed decreased GAG and increased collagen content compared with quadrangular cartilage. Within the DSA subsite, patients with presurgical NVC had the lowest GAG and highest collagen levels. This observation suggests that the biochemical composition of the DSA may contribute to its weakening, potentially resulting in its inability to withstand minor trauma and/or the effects of aging, ultimately leading to NVC. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support.

Total nasal reconstruction is a complex challenge due to the need to establish new internal lining, internal structural support, and external skin covering that is both functional and esthetic. The medial femoral condyle corticoperiosteal free flap represents an innovative option for restoration internal structure and internal nasal lining. When used in conjunction with a paramedian forehead flap, acceptable results in both function and esthetics can be achieved.

Age-Related Histologic and Biochemical Changes in Auricular and Nasal Cartilages.

OBJECTIVE: Analyze age-related changes in histologic features and biochemical properties of human auricular cartilage and two subsites of nasal cartilages (quadrangular cartilage and dorsal septal articulation with upper lateral cartilages). STUDY DESIGN: Prospective cross-sectional study of nasal and auricular cartilages from seventy-three (73) live donors. METHODS: Auricular cartilage (AC), quadrangular cartilage (QC), and dorsal septal cartilage articulation (DSA) with the upper lateral cartilage (ULCs) were collected intraoperatively. Histochemical staining was used: Safranin O for glycosaminoglycans (GAGs), Verhoeff's for elastin, and Masson's trichrome for collagen. ImageJ2 software was used to calculate cell count and percent stained for each cartilage type. R studio "ggplot" package was used to visualize age versus cell count or percent stained. RESULTS: Participant ages ranged from 20 to 77 years, average 46.5 years. There was a significant decline in GAGs with age for the DSA subsite, (n = 64, p < 0.001). Significant increase in collagen content with age was observed for DSA subsite (n = 66, p < 0.001) and the QC subsite (n = 64, p < 0.05). There was a statistically insignificant decline in elastin with age (n = 41, p = 0.309) for AC. Cell count declined with age at all cartilage subsites. CONCLUSION: Our findings confirm that there were age-related decreases in cartilage glycosaminoglycan content, and chondrocyte cell count in both auricular and nasal cartilages. We have also confirmed that collagen content increases with age for both auricular and nasal cartilage. The histologic findings while not statistically significant in all comparisons, provides additional evidence that there is some loss of structural integrity and flexibility in nasal and auricular cartilage with aging. LEVEL OF EVIDENCE: NA Laryngoscope, 134:1220-1226, 2024.

Casual Observers' Perception on the Aesthetics of the Butterfly Graft.

OBJECTIVE: The butterfly graft is an effective technique for improving the internal nasal valve, however, there is hesitancy among surgeons due to possible aesthetic changes. This study aims to determine if average observers rated the post-operative appearance of the butterfly graft negatively. METHODS: An online survey was distributed by social media to non-medical observers in which they rated either the pre-operative or post-operative appearance of 22 patients' noses (11 butterfly graft, 11 spreader graft). A heat map was used to determine if the supratip region was rated as the least aesthetically appealing. Post-operative ratings and heat maps of the butterfly graft patients were compared to pre-operative ratings as well as ratings of the spreader graft group. RESULTS: 226 observers responded. There was no difference in the pre-operative and post-operative rating of the butterfly graft group (58.27 vs. 58.00, p = 0.88) or the number of supratip regions selected as least attractive (165 vs. 169, p = 0.60). Similarly, there was no difference in post-operative ratings between the butterfly graft group and spreader graft group (58.00 vs. 58.21, p = 0.63) or in selection of the supratip as the least attractive region (169 vs. 172, p = 0.74). CONCLUSION: The butterfly graft did not negatively affect observers' opinion of patients' noses. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:2578-2583, 2023.

Body Dysmorphic Disorder in Adult Patients With an Orofacial Cleft: An Unseen Psychological Burden.

OBJECTIVES: Facial dysmorphic disorder (FDD), a variant of body dysmorphic disorder, occurs when individuals are preoccupied with perceived defects in their facial appearance. Cleft lip and/or palate (CL/P) requires many clinical interventions and has significant psychological impacts on a patient's perception of appearance. This study identified psychological burdens related to living as an adult with CL/P and characterizes the degree of FDD symptoms in an adult craniofacial population. METHODS: This was a prospective, single-center, cross-sectional case-control study using semi-structured interviews and symptom assessments at a university-based craniofacial center. Patients without CL/P undergoing non-cosmetic facial surgery were recruited as controls (n = 20). Patients with an orofacial cleft (n = 30) were recruited from medical and dental providers at the University of North Carolina. Body Dysmorphic Disorder-Yale Brown Obsessive Compulsive Scale (BBD-YBOCS) scores were collected from a control population and patients with CL/P to assess FDD severity. RESULTS: Demographic factors such age, biological sex, and ethnicity had no significant impact on FDD symptom scores. Patient with CL/P were more likely to have significant FDD symptoms (BDD-YBOCS greater than 16) than patients without CL/P (OR 10.5, CI95 2.7-41.1), and had a mean difference in FDD symptoms scores of 10.04 (p < 0.0001; CI95 5.5-14.6). Patients with CL/P seen by a mental health provider in the past 3 months had 3-fold lower overall FDD symptom scores (OR 0.081; CI95 0.0085-0.77). CONCLUSIONS: Adults with CL/P would benefit from treatment for cleft-specific needs and psychological support as they face unique stressors related to their appearance, including an increase in FDD-associated symptoms. This study emphasizes the importance of recognizing psychological symptoms and providing ongoing multidisciplinary care to adults with CL/P. LEVEL OF EVIDENCE: 3; Individual case-control study Laryngoscope, 133:818-821, 2023.

Anatomic Optical Coherence Tomography (aOCT) for Evaluation of the Internal Nasal Valve.

OBJECTIVES/HYPOTHESIS: To establish the utility of anatomic optical coherence tomography (aOCT) in evaluating internal nasal valve (INV). STUDY DESIGN: Anatomic specimen imaging study. METHODS: Fresh-harvested human specimen heads were evaluated using both computed tomography (CT) imaging as well as using aOCT. Scans were performed at three time points: 1) After septoplasty for cartilage harvest, 2) after placement of butterfly graft (BFG), and 3) after placement of bilateral spreader grafts (SG). Imaging data were then converted into 3D models of the nasal airway. CT- and aOCT-generated models were compared by both static volumetric analysis and computational fluid dynamics (CFD) to predict nasal resistance and pressure. RESULTS: Scans using aOCT showed comparable results to CT in terms of volumetric parameters both before and after intervention. Analysis of aOCT data by CFD demonstrated decrease in pressure after SG or BFG intervention. No statistically significant difference was observed when comparing CT- and aOCT-generated calculations of pressure or resistance. CONCLUSION: The INV can be imaged in a static fashion using aOCT technology. Advantages over traditional CT imaging include lack of exposure to radiation and rapid scan time. In addition, in-office use is possible as aOCT technology develops. Further investigation will be necessary to define the role of aOCT in the dynamic evaluation of this vital component of the nasal airway. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2148-2156, 2022.

Auricular avulsion injuries and reattachment techniques: A systematic review.

OBJECTIVES: Multiple surgical techniques exist in the acute management of auricular avulsion injuries, including reattachment of the tissue as a composite graft, reconstruction using local skin flaps, the pocket principle, the Baudet method, and microvascular repair. This review aimed to compare the success rates of reattachment methods in auricular avulsion injuries. METHODS: A PubMed search systematically identified cases in which (a) an auricular avulsion injury occurred and (b) reattachment was attempted. Search results were combined with an extensive review of references from published studies. In total, 148 cases were identified. Three reviewers independently graded the final aesthetic result of each case using a 5-point scale. The average grade of each repair was compared to the reattachment method to identify successful techniques. RESULTS: Microvascular repair was associated with a statistically significant higher success rate compared to all other reattachment methods. Composite graft reattachment also tended to generate better final aesthetic outcomes, but this difference was not statistically significant. CONCLUSION: Microvascular repair of the avulsed segment consistently demonstrated higher success rates. Composite graft reattachment should also be considered under the right circumstances. Overall, microvascular repair and composite graft reattachment should be considered the best options in cases of auricular avulsion repair. The authors share a major concern that other methods that rely on the use of periauricular skin will compromise any future attempts for secondary reconstruction, such as staged procedures using costal cartilage grafts. Manipulation of these tissues and in particular burying of the avulsed ear cartilage is discouraged. LEVEL OF EVIDENCE: 4.

Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts.

OBJECTIVES/HYPOTHESIS: Internal nasal valve compromise is a major cause of nasal obstruction, with a growing number of ways to treat this condition. In this study, we compared the effects of butterfly graft, spreader graft, and the bioabsorbable nasal implant on nasal airflow resistance. STUDY DESIGN: Cadaver study. METHODS: Computational fluid dynamics (CFD) simulations were completed from nine preoperative and postoperative cadaveric subjects. Each cadaveric head underwent placement of a bioabsorbable nasal implant (BNI) (Spirox Latera; Stryker ENT, Plymouth, MN), butterfly graft, or spreader graft. Pre- and postoperative computed tomography (CT) scans were used to generate three-dimensional models of the nasal airway used in steady-state CFD simulations of airflow and heat transfer during inspiration. RESULTS: Butterfly graft placement resulted in a mean improvement in nasal airway resistance of 24.9% (±7.3), whereas BNI placement resulted in a 6.7% (±1.2) improvement, and spreader graft placement also resulted in a consistent improvement of 2.6% (±13.5). Pressure within the main nasal cavity was consistently lower following butterfly graft placement versus a spreader graft or BNI. Butterfly and spreader graft placement also resulted in modest improvements in airflow allocation, whereas BNI demonstrated more variation (-1% to 12%). Heat flux was not significantly different; however, a small improvement in total heat flux was seen with all three interventions. CONCLUSIONS: The results of this study demonstrate reduction in nasal airway resistance in all three surgical interventions, with the butterfly graft demonstrating superiority to the other two techniques. However, these data only reflect a static environment and not dynamic changes in airflow seen during respiration. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E817-E823, 2020.

Teaching nasal analysis to otolaryngology residents.

PURPOSE: This prospective cohort study was completed to evaluate a systematic approach for teaching nasal analysis to otolaryngology-head and neck surgery residents. METHODS: Residents from each post graduate year (PGY) were randomized to the control group or study group. Residents in the study group were given a 10-slide PowerPoint (Microsoft Corp) instruction on nasal analysis using the standard sequence of photographs and anatomic elements to describe in each view. All residents were given the standard sequence of photographs of 3 patients for assessment on nasal analysis. Then 12-14 weeks later all residents were re-evaluated using photographs of 3 new patients. The results were blinded and graded using an 18 point scale modified from a previous publication [1]. RESULTS: Twenty otolaryngology-head and neck surgery residents completed the study. Analysis was performed with and without multivariate regression modeling to adjust for PGY, sex, and number of rhinoplasties performed. The study group had overall higher scores in both the initial and follow up assessment, specifically with subsite-specific dorsal deviation, tip projection, and nostril symmetry. Neither group obtained high scores in facial symmetry, skin thickness, tip shape and contour, and radix position at initial or re-assessment. CONCLUSION: Nasal analysis is a complex task. A lecture on a systemic approach to facial analysis given to a group of residents, who performed significantly better on facial analysis cases than controls. Further research in providing feedback, periods of rehearsal or testing, or focused selected elements with serial exposure can be considered.

Reconstruction of Defects Involving the Lip and Chin.

Successful perioral reconstruction is the result of consideration of both functional and esthetic goals. The lips are complex esthetic units with multiple tissue layers and distinct anatomic landmarks. Reconstruction can be difficult due to variables affecting the defect, such as size, depth, location, and involvement of adjacent subunits. There are many local flaps that can be used to match the complex tissue layers and anatomic landmarks. Use of the same reconstructive principles can be applied to secondary reconstruction to attain a successful outcome. This article focuses on local reconstructive options for defects of the lip and chin.

Correction: Molecular Subtypes in Head and Neck Cancer Exhibit Distinct Patterns of Chromosomal Gain and Loss of Canonical Cancer Genes.

[This corrects the article DOI: 10.1371/journal.pone.0056823.].

Comparison of Airflow Between Spreader Grafts and Butterfly Grafts Using Computational Flow Dynamics in a Cadaveric Model.

IMPORTANCE: Nasal valve compromise is a major cause of nasal obstruction, and multiple methods have been developed to address it. OBJECTIVE: To compare nasal airflow resistance, airflow partitioning, and mucosal cooling (heat flux) before and after 2 surgical interventions, butterfly and spreader graft placement, used to treat nasal valve compromise. DESIGN, SETTING, AND PARTICIPANTS: In this cadaveric tissue study, 4 fresh cadaveric heads underwent both spreader graft and butterfly graft surgical procedures in alternating sequence in March 2016. Preoperative and postoperative computed tomographic scans were used to generate 3-dimensional (3-D) models of the nasal airway. These models were then used in steady state computational fluid dynamics simulations of airflow and heat transfer during inspiration. INTERVENTION: Butterfly and spreader graft techniques. MAIN OUTCOMES AND MEASURES: Nasal airflow resistance, airflow partitioning, and heat flux. RESULTS: Donors 1, 2, and 3 were white males; donor 4, a white female. Computational fluid dynamics simulations during inspiration in 3-D models generated from preoperative and postoperative computed tomographic scans of the 4 cadaveric heads indicated reductions from preoperative values in nasal airflow resistance associated with both butterfly grafts (range, 20%-51%) and spreader grafts (range, 2%-29%). Butterfly grafts were associated with a greater reduction in nasal airflow resistance in models of all 4 cadaveric heads. Changes from preoperative values for heat flux, a biophysical variable that correlates with the subjective sensation of nasal patency, were more variable, ranging from -11% to 4% following butterfly grafts and -9% to 10% following spreader grafts. The preoperative airflow allocation in the left and right nostrils improved consistently with the butterfly graft. With the spreader graft, there were improvements for donors 1 and 4, but the allocations were worse for donors 2 and 3. CONCLUSIONS AND RELEVANCE: The results of this study suggest that the more recently developed butterfly graft technique may be associated with a similar level of improved nasal airflow as that observed with the use of a spreader graft in nasal valve compromise. Both interventions were associated with comparable changes in heat flux. Because this study addressed only static internal nasal valve stenosis, even greater differences in air flow and heat flux between the 2 techniques may be anticipated in a dynamic model. Further investigation in patients is warranted. LEVEL OF EVIDENCE: NA.

Reconstruction of nasal defects: contemporary approaches.

PURPOSE OF REVIEW: There are many well-established principles and surgical techniques for nasal reconstruction. The purpose of this study is to describe contemporary reconstruction of nasal defects. The unique anatomic features of the nose make this a challenging task. Although obtaining an optimal esthetic result is always the goal of reconstruction, maintenance and restoration of nasal function are of equal importance. RECENT FINDINGS: The first step of nasal reconstruction is a thoughtful analysis of the defect. The best surgical option will provide the patient with an excellent esthetic result and nasal function. Depending upon the extent of the defect as well as the anatomic site, a local flap, full-thickness skin graft, composite graft, or interpolated flap will provide the optimal result. The decision will depend on the surgeon's experience and expertise, as well as expectations and desires of the patient. Many cutaneous defects will require not only reconstruction of the defect, but also cartilage grafts to provide nasal contour and support. Most large or complex defects will require a paramedian forehead flap for reconstruction along with cartilaginous and/or bony support, as well as a lining flap. SUMMARY: This study highlights recent advances in nasal reconstruction and novel modifications of well-accepted traditional techniques.

Safety and Efficacy of Expanded Polytetrafluoroethylene Implants in the Surgical Management of Traumatic Nasal Deformity.

IMPORTANCE: The ideal alloplastic implant for correction of traumatic nasal deformity has not been adequately examined. OBJECTIVE: To evaluate the safety profile and postoperative results of expanded polytetrafluoroethylene (ePTFE) implants used in functional nasal surgery (FNS) in the setting of traumatic nasal deformity. DESIGN, SETTING, AND PARTICIPANTS: We conducted a 13-year retrospective medical chart review for patients treated at a tertiary academic facial plastic and reconstructive surgery practice between July 1999 and July 2012. A total of 404 FNS procedures were performed by a single surgeon during this period, 255 to repair traumatic deformities, 35 of these involving ePTFE implants. Patient demographics, medical comorbidities, operative and technical considerations, functional and aesthetic results, complications, and postoperative course findings were collected from patient records. In addition, preoperative and postoperative photographic documents were examined. EXPOSURES: Functional nasal surgery. MAIN OUTCOMES AND MEASURES: Postoperative complications or presentations necessitating revision. RESULTS: A total of 404 patients (197 male, 207 female) underwent FNS. Of those, 255 procedures were to treat traumatic deformities. Forty patients altogether required the use of an ePTFE implant, 35 of those 40 deformities being associated with a traumatic injury. One of the 35 patients in the ePTFE-repaired traumatic deformities group experienced postoperative infection. This patient ultimately developed exposure after the infection failed to resolve with oral antibiotics, and the implant was removed. An additional patient in the ePTFE group required revision of the implant owing to contour irregularity and aesthetic concerns. No infections or other complications occurred among the 220 patients with traumatic deformity treated with autologous grafts. Analysis of other variables including sex, tobacco use, diabetes, immunosuppression, implant thickness, suture material, and prior septorhinoplasty were not associated with increased rate of infection (P > .05 for all). CONCLUSIONS AND RELEVANCE: In the setting of traumatic nasal deformities requiring FNS, ePTFE implants can be used at the level of the nasal dorsum, where soft tissue coverage is often adequate, with a low risk of complications.